Discharge planning is the key element in managing Medicare Part A length of stay. A home assessment can significantly affect the process.

Completing a detailed review of the home environment and the patient’s ability to function in that home environment will help identify discharge needs, ensure safe and successful discharge to home for the patient, and may lengthen the rehabilitation stay for the facility.

It is suggested that the completion of a home assessment is communicated at the initiation of the therapy program. The purpose and expectations need to be discussed with the patient and family as part of discussing the therapy plan of care and goals. This communication helps set the foundation for the patient for a successful rehabilitation program as well as successful discharge to home.

Conducting a home assessment involves taking the patient out of a controlled environment and assessing his or her abilities in a “real life” environment. The home assessment is the opportunity not only to assess whether the patient will be successful upon discharge but a determination of what needs to be further addressed in therapy at the facility to ensure a safe and successful discharge to home. Upon completion of the home assessment, new goals are established with continued treatment to focus on those more specific areas that need to be addressed prior to discharge.

Continued treatment following this home assessment may be required to address the higher-level skills required in order for patients to experience a safe and successful discharge to home.

These higher-level skills may include:

Physical mobility

* Ability to incorporate restrictive precautions (hip, back, sternal, cardiac) into daily routine, functional mobility and tasks

* Advanced transfers; low surface, soft surface, no armrests, car

* Multi-surface gait; grass (soft mat simulates grass), gravel, brick; inside and outside 

* Opening doors, pushing/pulling

* Fall recovery 

Activities of daily living

* Dressing; includes management of braces, TED hose, obtaining and returning clothing to closet or dresser

* Tub and shower transfers

* Bathroom safety including access of cupboards

* Empty and clean bedside commode

Instrumental ADLs

* Self-medication (including oxygen, opening containers, timing)

* Sweeping/mopping/ vacuuming; all require good trunk control and balance

* Spill management

* Pet care; food, water, litter box

* Laundry; washer, dryer, ironing

* Kitchen skills and safety

* Meal planning and preparation

* Retrieve objects from high/low cupboards, bottom of fridge

* Safe use of appliances; coffee maker, toaster, microwave, dishwasher

* Putting away groceries in cupboard/fridge

* All patients discharging to home or an assisted living facility should be able to obtain, prepare and transport drinks and light snacks, even if they are not primarily responsible for meal preparation

Community re-entry

* Ability to cross street; safety with crosswalk, velocity

* Retrieve mail

* Grocery shopping, including transport of bags

* Banking and money management

* Restaurant; access, choice of meals within restrictions

* Car transfers and access public transportation

Cognitive Skills

* Managing finances; budgeting, banking, bill paying

* Response to emergencies

* Using telephone or alert system

* Reading; following instructions

* Telling time; important for appointments and medication management

Kris Mastrangelo, OTR, MBA, LNHA, is president and CEO of Harmony Healthcare International, a consultancy that provides onsite auditing of MDS and associated medical records.